Therapy for Pediatric Clients With Mood Disorders Case Study
Therapy for Pediatric Clients With Mood Disorders Case Study
Therapy for Pediatric Clients with Mood Disorders An African American Child Suffering From Depression
BACKGROUND INFORMATION
The client is an 8-year-old African American male who arrives at the ER with his mother. He is exhibiting signs of depression.
· Client complained of feeling “sad”
· Mother reports that teacher said child is withdrawn from peers in class
· Mother notes decreased appetite and occasional periods of irritation
· Client reached all developmental landmarks at appropriate ages
· Physical exam unremarkable
· Laboratory studies WNL
· Child referred to psychiatry for evaluation
MENTAL STATUS EXAM
Alert & oriented X 3, speech clear, coherent, goal directed, spontaneous. Self-reported mood is “sad”. Affect somewhat blunted, but child smiled appropriately at various points throughout the clinical interview. He denies visual or auditory hallucinations. No delusional or paranoid thought processes noted. Judgment and insight appear to be age-appropriate. He is not endorsing active suicidal ideation, but does admit that he often thinks about himself being dead and what it would be like to be dead.
You administer the Children’s Depression Rating Scale, obtaining a score of 30 (indicating significant depression)
RESOURCES
§ Poznanski, E., & Mokros, H. (1996). Child Depression Rating Scale–Revised. Los Angeles, CA: Western Psychological Services.
Decision Point One
Begin Zoloft 25 mg orally daily
RESULTS OF DECISION POINT ONE
· Client returns to clinic in four weeks
· No change in depressive symptoms at all
Decision Point Two
Increase dose to 37.5 mg orally daily
RESULTS OF DECISION POINT TWO
· Client returns to clinic in four weeks
· Depressive symptoms decrease by 20%. Client reports feeling a little bit better
Decision Point Three
Maintain current dose
Guidance to Student At this point, sufficient symptom reduction has not been realized. Should either increase dose or consider different SSRI. At 8 weeks post-initiation of therapy, there should have been a significant (as defined as 50%) decrease in symptoms. This would be considered an adequate trial of antidepressant and change in dose or to a different agent would be appropriate.
Write a 2-page narrative in APA format that addresses the following:
· Explain the circumstances under which children should be prescribed drugs for off-label use. Be specific and provide examples.
· Describe strategies to make the off-label use and dosage of drugs safer for children from infancy to adolescence. Include descriptions and names of off-label drugs that require extra care and attention when used in pediatrics.
Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.) St. Louis, MO: Elsevier.
· Chapter 9, “Drug Therapy in Pediatric Patients” (pp. 58—60)
Corny, J., Lebel, D., Bailey, B., & Bussieres, J. (2015). Unlicensed and off-label drug use in children before and after pediatric governmental initiatives. The Journal of Pediatric Pharmacology and Therapeutics, 20(4), 316–328. Retrieved from /orders/www.ncbi.nlm.nih.gov/pmc/articles/PMC4557722/
This article highlights pediatric governmental initiatives to prevent unlicensed and off-label drug use in children. Review these initiatives and guidelines and how they might impact your practice as an advanced practice nurse.
Panther, S. G., Knotts, A. M., Odom-Maryon, T., Daratha, K., Woo, T., & Klein, T. A. (2017). Off-label prescribing trends for ADHD medications in very young children. The Journal of Pediatric Pharmacology and Therapeutics, 22(6), 423–429. doi:10.5863/1551-6776-22.6.423
This study examines the frequency of off-label prescribing to children and explores factors that impact off-label prescribing. This study also examines off-label prescribing to children with ADHD.
Children, like adults, deal with variety of health issues, but they also have issues that are more prevalent within their population. One issue that significantly impacts children is the prescription of drugs for off-label use. How do you determine the appropriate use of off-label drugs in pediatrics?
Are there certain drugs that should be avoided with pediatric patients?
The unapproved use of approved drugs, also called off-label use, with children is quite common. This is because pediatric dosage guidelines are typically unavailable, since very few drugs have been specifically researched and tested with children.
When treating children, prescribers often adjust dosages approved for adults to accommodate a child’s weight. However, children are not just “smaller” adults. Adults and children process and respond to drugs differently in their absorption, distribution, metabolism, and excretion
Week 2: Therapy for Pediatric Clients With Mood Disorders
Mood disorders can impact every facet of a child’s life, making the most basic activities difficult for clients and their families. This was the case for 13-year-old Kara, who was struggling at home and at school. For more than 8 years, Kara suffered from temper tantrums, impulsiveness, inappropriate behavior, difficulty in judgment, and sleep issues. As a psychiatric mental health nurse practitioner working with pediatric clients, you must be able to assess whether these symptoms are caused by psychological, social, or underlying growth and development issues. You must then be able recommend appropriate therapies.
This week, as you examine antidepressant therapies, you explore the assessment and treatment of pediatric clients with mood disorders. You also consider ethical and legal implications of these therapies.
Assignment: Assessing and Treating Pediatric Clients With Mood Disorders
When pediatric clients present with mood disorders, the process of assessing, diagnosing, and treating them can be quite complex. Children not only present with different signs and symptoms than adult clients with the same disorders, but they also metabolize medications much differently. As a result, psychiatric mental health nurse practitioners must exercise caution when prescribing psychotropic medications to these clients. For this Assignment, as you examine the client case study in this week’s Learning Resources, consider how you might assess and treat pediatric clients presenting with mood disorders.
Note: This Assignment is the first of 10 assignments that are based on interactive client case studies. For these assignments, you will be required to make decisions about how to assess and treat clients. Each of your decisions will have a consequence. Some consequences will be insignificant, and others may be life altering. You are not expected to make the “right” decision every time; in fact, some scenarios may not have a “right” decision. You are, however, expected to learn from each decision you make and demonstrate the ability to weigh risks versus benefits to prescribe appropriate treatments for clients.
Learning Objectives
Students will:
· Assess client factors and history to develop personalized plans of antidepressant therapy for pediatric clients
· Analyze factors that influence pharmacokinetic and pharmacodynamic processes in pediatric clients requiring antidepressant therapy
· Evaluate efficacy of treatment plans
· Analyze ethical and legal implications related to prescribing antidepressant therapy to pediatric clients
Learning Resources
Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus. Therapy for Pediatric Clients With Mood Disorders Case Study
Required Readings
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.
Note: To access the following chapters, click on the Essential Psychopharmacology, 4th ed tab on the Stahl Online website and select the appropriate chapter. Be sure to read all sections on the left navigation bar for each chapter.
- Chapter 6, “Mood Disorders”
- Chapter 7, “Antidepressants”
Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.
Note: To access the following medications, click on the The Prescriber’s Guide, 5th ed tab on the Stahl Online website and select the appropriate chapter. Be sure to read all sections on the left navigation bar for each chapter.
Review the following medications:
- amitriptyline
- bupropion
- citalopram
- clomipramine
- desipramine
- desvenlafaxine
- doxepin
- duloxetine
- escitalopram
- fluoxetine
- fluvoxamine
- imipramine
- ketamine
- mirtazapine
- nortriptyline
- paroxetine
- selegiline
- sertraline
- trazodone
- venlafaxine
- vilazodone
- vortioxetine
Rao, U. (2013). Biomarkers in pediatric depression. Depression & Anxiety, 30(9), 787–791. doi:10.1002/da.22171
Note: Retrieved from Walden Library databases.
Poznanski, E., & Mokros, H. (1996). Child Depression Rating Scale–Revised. Los Angeles, CA: Western Psychological Services.
Note: Retrieved from Walden Library databases.
Required Media
Note: This case study will serve as the foundation for this week’s Assignment.
Optional Resources
El Marroun, H., White, T., Verhulst, F., & Tiemeier, H. (2014). Maternal use of antidepressant or anxiolytic medication during pregnancy and childhood neurodevelopmental outcomes: A systematic review. European Child & Adolescent Psychiatry, 23(10), 973–992. doi:10.1007/s00787-014-0558-3 Therapy for Pediatric Clients With Mood Disorders Case Study
Gordon, M. S., & Melvin, G. A. (2014). Do antidepressants make children and adolescents suicidal? Journal of Pediatrics and Child Health, 50(11), 847–854. doi:10.1111/jpc.12655 Therapy for Pediatric Clients With Mood Disorders Case Study
Seedat, S. (2014). Controversies in the use of antidepressants in children and adolescents: A decade since the storm and where do we stand now? Journal of Child & Adolescent Mental Health, 26(2), iii–v. doi:10.2989/17280583.2014.938497
To prepare for this Assignment:
· Review this week’s Learning Resources. Consider how to assess and treat pediatric clients requiring antidepressant therapy.
The Assignment
Examine Case Study: An African American Child Suffering From Depression. You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.
· At each decision point stop to complete the following:
o Decision #1
§ Which decision did you select?
§ Why did you select this decision? Support your response with evidence and references to the Learning Resources.
§ What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
§ Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?
o Decision #2
§ Why did you select this decision? Support your response with evidence and references to the Learning Resources.
§ What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
§ Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?
o Decision #3
§ Why did you select this decision? Support your response with evidence and references to the Learning Resources.
§ What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
§ Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?
· Also include how ethical considerations might impact your treatment plan and communication with clients.
Note: Support your rationale with a minimum of three academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement. Therapy for Pediatric Clients With Mood Disorders Case Study
When pediatric patients present with mood disorders, the process of assessing, diagnosing, and treating them can be quite complex. Children not only present with different signs and symptoms than adult patients with the same disorders, they also metabolize medications much differently. Yet, there may be times when the same psychopharmacologic treatments may be used in both pediatric and adult cases with major depressive disorders. As a result, psychiatric nurse practitioners must exercise caution when prescribing psychotropic medications to these patients. For this Assignment, as you examine the patient case study in this week’s Learning Resources, consider how you might assess and treat pediatric patients presenting with mood disorders.
To prepare for this Assignment:
- Review this week’s Learning Resources, including the Medication Resources indicated for this week.
- Reflect on the psychopharmacologic treatments you might recommend for the assessment and treatment of pediatric patients requiring antidepressant therapy.
The Assignment: 5 pages
Examine Case Study: An African American Child Suffering From Depression.
You will be asked to make three decisions concerning the medication to prescribe to this patient. Be sure to consider factors that might impact the patient’s pharmacokinetic and pharmacodynamic processes.
At each decision point, you should evaluate all options before selecting your decision and moving throughout the exercise. Before you make your decision, make sure that you have researched each option and that you evaluate the decision that you will select. Be sure to research each option using the primary literature.
Introduction to the case (1 page)
- Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient.
Decision #1 (1 page)
- Which decision did you select?
- Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
- Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
- What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
- Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Decision #2 (1 page)
- Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
- Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
- What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
- Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Decision #3 (1 page)
- Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
- Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
- What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
- Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Conclusion (1 page)
Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature.
Case Study
Therapy for Pediatric Clients with Mood Disorders An African American Child Suffering From Depression
BACKGROUND INFORMATION
The client is an 8-year-old African American male who arrives at the ER with his mother. He is exhibiting signs of depression.
· Client complained of feeling “sad”
· Mother reports that teacher said child is withdrawn from peers in class
· Mother notes decreased appetite and occasional periods of irritation
· Client reached all developmental landmarks at appropriate ages
· Physical exam unremarkable
· Laboratory studies WNL
· Child referred to psychiatry for evaluation
· Client seen by Psychiatric Nurse Practitioner
MENTAL STATUS EXAM
Alert & oriented X 3, speech clear, coherent, goal directed, spontaneous. Self-reported mood is “sad”. Affect somewhat blunted, but child smiled appropriately at various points throughout the clinical interview. He denies visual or auditory hallucinations. No delusional or paranoid thought processes noted. Judgment and insight appear to be age-appropriate. He is not endorsing active suicidal ideation but does admit that he often thinks about himself being dead and what it would be like to be dead.
The PMHNP administers the Children’s Depression Rating Scale, obtaining a score of 30 (indicating significant depression)
RESOURCES
§ Poznanski, E., & Mokros, H. (1996). Child Depression Rating Scale–Revised. Los Angeles, CA: Western Psychological Services.
1-Decision Point One
Select what the PMHNP should do:
1-Begin Zoloft 25 mg orally daily
Begin Zoloft 25 mg orally daily
RESULTS OF DECISION POINT ONE
· Client returns to clinic in four weeks
· No change in depressive symptoms at all
egin Zoloft 25 mg orally daily
2Increase dose to 37.5 mg orally daily
· Client returns to clinic in four weeks
· Depressive symptoms decrease by 20%. Client reports feeling a little bit better
At this point, sufficient symptom reduction has not been realized. Should either increase dose or consider different SSRI. At 8 weeks post-initiation of therapy, there should have been a significant (as defined as 50%) decrease in symptoms. This would be considered an adequate trial of antidepressant and change in dose or to a different agent would be appropriate.
-Begin Wellbutrin 75 mg orally BID
· Client returns to clinic in four weeks
· Reduction in The Children’s Depression Rating Scale by 5 points overall, but with complaints of nausea, vomiting, and diarrhea
Decrease dose for 7 days then return to previous 10 mg day dose
Guidance to Student
Guidance to Student
The PMHNP has two equally compelling choices at this point. The client has only been taking the current drug at its current dose for 4 weeks. It would be appropriate to continue at current dose. Additionally, the PMHNP could also increase the dose to 20 mg orally daily. A discussion of risk/benefits should be had with the childs guardian regarding this and collaborative decision making should occur. There is no indication at this point that augmentation agents are required as the child is showing a partial response to therapy.
2-RESULTS OF DECISION POINT TWO
Begin Paxil 10 mg orally daily
Begin Paxil 10 mg orally daily
· Client returns to clinic in four weeks
· Reduction in The Children’s Depression Rating Scale by 5 points overall, but with complaints of nausea, vomiting, and diarrhea
· Decrease dose for 7 days then return to previous 10 mg day dose
Client returns to clinic in four weeks
· Nausea, vomiting, diarrhea subsides with dose reduction, but returns with reinitiation of 10 mg dose
· Attempt to decrease dose for another 7 days then return to 10 mg dose
· Guidance to Student
Temporarily decreasing the drug for 7 days and then increasing is an acceptable option- however, if the side effects return with the reinitiation of the dose, the PMHNP will need to select a different agent as these side effects are unfavorable to the client and may result in refusal to take treatment. Also, continuing to drop medication dose to subtherapeutic level will do minimal to treat depressive symptoms. Changing to a different SSRI would be the ideal choice as not all SSRIs have the same side effect profile in all clients. It would not be appropriate to increase the dose at this time as it would most likely result in increased intensity of side effects.
3-Begin Wellbutrin 75 mg orally BID
Begin Wellbutrin 75 mg orally BID
· Client returns to clinic in four weeks
· Child is unable to fall asleep at night
Change from immediate release to extended release 150 mg orally daily in the morning
ive second dose of the day at 1:00 pm in the afternoon
· Client returns to clinic in four weeks
· Child’s sleep patterns return to baseline. No change in depressive symptoms
Change to SSRI
Guidance to Student The PMHNP can continue drug therapy for another 4 weeks, however, it is discouraging that there have been no changes in depressive symptomatology. Increasing the dose to 300 mg orally daily may be appropriate if the child is tolerating the medication well. Changing to an SSRI may also be appropriate, but it may be more prudent to give the Wellbutrin at an appropriate dose for an adequate duration of therapy before switching therapeutic classes.
Change to Lexapro 10 mg orally daily
Give second dose of the day at 1:00 pm in the afternoon
· Client returns to clinic in four weeks
· No change in sleeping patterns, child is getting more difficult to wake for school
3-Decision Point Three
· Begin Wellbutrin 75 mg orally BID Begin Wellbutrin 75 m
· Client returns to clinic in four weeks
· Child is unable to fall asleep at night
Change to Lexapro 10 mg orally daily
· Client returns to clinic in four weeks
· Child is tolerating Lexapro, and is sleeping at night. There is a 40% reduction in symptoms
Decrease dose for 7 days then return to previous 10 mg day dose
· Client returns to clinic in four weeks Nausea, vomiting, diarrhea subsides with dose reduction, but returns with reinitiation of 10 mg dose
Attempt to decrease dose for another 7 days then return to 10 mg dose
Temporarily decreasing the drug for 7 days and then increasing is an acceptable option- however, if the side effects return with the reinitiation of the dose, the PMHNP will need to select a different agent as these side effects are unfavorable to the client and may result in continued refusal to take treatment. Changing to a different SSRI may be appropriate if the trial decrease of dose is unsuccessful and if the nausea, vomiting, and diarrhea return with reinitiation of 20 mg orally daily. Changing the medication may be appropriate as not all SSRIs have the same side effect profile in all client.
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